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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL'1"N AN'~ FIUMAIV SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGMI%1 L (#EC[~B,i~ (~N FILE IN/TM
<br />THE NEBRASKA HEALTW AND HUMAN SERVICES SYSTEM, V/7'AL S~'AT~`~~~H/H/CH'IS ,
<br />'TME LEGAL DEPOSITORY FOR VITAL REC019DS. ~Y `~ '' l L
<br />DATE OF ISSUANCE - • ,`
<br />TAINLEY(S "6fJCCIPEA
<br />N~o ~ NAB a~ KA 2 0 Q ~ O S 7 2 5 ~p ~:tf aryl u~A~r s~'~ ~ ~ ,
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<br />STATE OF NEBRASKA-bEPARTMENTOF WEALTH ANb HUMAN SERVICES f"IN~A7~>v~,Nb 5UPPOR7~ ~ ~ ~ C O O
<br />rCQ71CIheTG r1~ I'1FATH " J
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<br />DATE OF DEATH (Mo
<br />2 SEX "~ ~~
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<br />1. DECEDENT'S•NAME (Flrel, Mlddte, Lasl, 5ulllx)
<br />s Female ' + February 13, 2006
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<br />• 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE-Last Birthday 54. UNDER 1 YEAR 5c. UNDER i DAY 8. DATE DF BIRTH (Mo., bey, Yr.)
<br />'S.'
<br />:~;' (Yrs.) MOS. bAY5 HOURS MINS.
<br />Masan City, Nebtaska 6S February 14, 1940
<br />; ~:
<br /> 7. SOCIAL SECURITY NUMBER ~ Ba. PLACE OF bEATH
<br />!~!~",--.
<br />~ 5D5-52-4~~6 HOSPITAL: ^Inpetlenl S1Il~B: ^NursingHomelLTC ^HospiceFacllity
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<br />eb. FACILITY•NAME (If not Inslltutlvn, glue street and number) (,~ ERlOutpellanl SCI becedenl'aHoma
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<br />503 W. Louise ^ DDa a otner(spanuy)
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<br />~';, Bc. CITY OR TOWN OF DEATH (Include Zlp Gade) Bd. COUNTY OF DEATH
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<br />~5 Grand Island 68$p1 Hall
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<br />Ba.RESIDENCE•STATE
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<br />9b.000NTY
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<br />9c.CITYDRT~WN
<br />~. Nebraska Tull Grand Island _
<br /> 9d. STREETAND NUMBER 8e. APT. NO 81. ZIP CODE 8g. INSIDE CITY LIMITS
<br />.~ 503 W. Louise 68801 ~ YES ^ NO
<br />~~"
<br />~' t da. MARITAL STATUS AT TIME OF DEATH ^ Married C7 Never Married 186. NAME OF SPOUSE (First, Middle, Lesl, Suf1lx) It wile, glue maiden name.
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<br />utseparatad ~Wldowed ^Dlvvicnd ^Unknvwn R011a1d Owings (Deceased
<br />6
<br />^ Married
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<br />11. FATHER'5•NAME (First, Middle, Lasl, Sultlx) 12. MOTMER'S-NAME (First, Middle, Malden Surname)
<br />~`~ Dwigk-t Brundiege Violet Lewis
<br />N:
<br />IX`,
<br />13. EVER IN U.S. ARMED FORCE57 Glva datesvl service Ryes. 14a.INFORMANT•NAME 14b. RELATIONSHIP TO bECEDENT
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<br />~' ) NO LaDonna Wiecznrek Daughter.
<br />vrunk
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<br />15. ME7HOb OF DISPOSITION 18a. EMBA ER (GNATUR 186. LICENSE N0. 1 Bc. DATE (Mo., Day, Yr. )
<br />~ ~
<br /> ~ 119X Fib. 16, ~DD~
<br />~Burlal ^bvnadvn ,~,Lf<r'' r//r~
<br /> ^ Cremation ^ Entombment 18d. CEMETERY, CREM~YA Y OR OTHER LOCA7 ON CITY I TOWN STATE
<br /> gRemaval ^Other(Speclly) Westlawn Memorial Park Cemetery, Grand Tsland, Nebraska
<br />'%a~~~S4' 17a. FUNERAL HOME NAME ANb MAILING ADDRESS (Street, Clly orTown, 31ate) _ 17b. Zip Code
<br />
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<br />'~~~ ivingston-Sondermann Funeral Borne, 601 N, Webb Road, Grand Island, NE 68803
<br /> ~
<br />)~~~ ~'.,~ 18. PART I. Enter the ehaln..ALaxanis•-dlaeaeea, In)urlea, yr cvmpllcatlvna••ihat directly caused the death. DO NOT enter terminal evanta such es cardiac arrest, APPROXIMATE
<br /> INTERVAL
<br />I
<br /> respiratory arrest, or ventricular Ilbrlllallon without showing the ollolvgy. DO NOT AB9REVIATE. Enter only ono cause on a Ilne. Add addlllvnel Ilnes II necessary. I
<br /> IMMEDIATE CAUSE: I onset lc death
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<br />'` :. IMMEbIATECAU5E(Flnal (a) ti~,~~~~U L•1~'W C~i..i~rl'1-t.'1(lytGG2~GV+~~ J
<br />-,,-~ dlaesaevrcondltlon reauging bUE TD, DR AS A CONSEQUENCE DF: I onset to death
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<br />~~'~'~i Indeath) I
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<br />5equenllally Ilet cvndlllvne, II
<br /> any, leading to Ihecause hated DUE T0, OR AS'A CONSEQUENCE OF: I onset tv death
<br /> do Ilrie a. I
<br /> EnterlheUNDERLVINGCAUSE I
<br /> (dleeasevrlnjurythellnlllated (c) _
<br /> theeventaresullinglndeeth) bUE T0, OR AS A CONSEQUENCE QF: i onseuv death
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<br />18. PART IL OTHEflSIGNIFICANT CDNbITIDNS-Candlllons cvnirl6uting lv the death 6u1 not resulting In the underlying cause given In PART I. 1g. WA5 MEDICAL EXAMINER
<br />~> T ~ M ~ ~ .Y~ i ~~ OR CORONER CONTACTEbT
<br />1-N _tN
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<br />' ~ l 1
<br />r.i.~t.a~w )
<br />^ YES ~ NO
<br />Gti'~`LUUJj l~il
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<br />~~~~ Tp.IFFEMALE: ~ 21a.MANNEROFOEATH 214.IFTRANSPORTATIONINJURY 21c.WASANAUTOPSYPERFORMED7
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<br />~Y ^ brlverlOperator •Y
<br />Nol regnant wllhin past year Natural ^ Homicide
<br />ND
<br />^ YES
<br />~
<br />`,~ nanlalllmevldeath ^Accldenl^Pvndinglnvvstlgallen QPassenger
<br />mm.
<br />^ Prag
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<br />~ ~ -~~. rvot pieyrianl, bdt ra nStn wimiit 4Z vays i;i death _ ~ Cl F'edeRl nn_.,,W __.,_ „ „ ,
<br />p 8 ~~ USulclde UCouldnvl6edblaimfned~ - ~- ~~• ~ '~' ~-.,rc T=`~~°~"~~`~"uau..e~~.~~n--... •.
<br />^ Nol pregnant, but pregnen143 days Iv 1 year6elvre death ^ Dlher (Speclly) COMPLETE CAUSE OF bF4THT
<br />•~
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<br />T Q Unknown If pregnant wllhin the pass year ^ YES CI NO
<br />
<br />22e. DATE of INJURY (Mo., Day, Yr.) 224. TIME OF INJURY 22c. PLACE OF INJURY-Al home, term, street, lactnry, clllce building, conetrucllon site, etc. (Speclly)
<br />!,;, m ; m
<br />-~~+ 22d.INJURYA7 WORKT 22e. DESCRIBE HDW INJURY OCCURRED
<br /> ^ YE5 ^ NO
<br /> •221. LOCATION OF INJURY • STREET 8 NUMBER, APT. N0. ~~ CRY/FOWN STATE ~ ZIP CObE ____
<br /> 23a. DATE OF bEATH (Mn., Day, Yr.) ~ ~ 24a. DATE SIGNED (Mv., Day,Yr.) 24b.TIME OF DEATH
<br />m
<br /> ~'~ Februar 13, 2D06 ~'.~ ~ -
<br />~ 24o.PMONOUNCEbbEAb(Mv.,Day,Yr,) 24d.TIMEPRONOUNCEDbEAD
<br />. ~N 23b.DATE5IGNED(Mv.,Day,Yr.) 23aTIMEapbEATH ~~~
<br />~~ ~
<br />E~ z~ February 15, 200 3: DD a m E h a m
<br />~
<br />
<br />~"`~;,le,~ 24e. On the Gaels of examinatldn and/or Investlgatlon, in my opinion death occurred at
<br />~ ~ ~ 23d. To Iha best el my knowledge, death occurred al the Ilme, dale end place ~ ~ ~
<br />i 7a
<br />date end place and due tv the cause(s) stated. (Signature and Title) 'r
<br />the Ilme
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<br />ure an
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<br />~ ~ and due to the cause(s) elate
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<br />25.DIDTOBACCOUSECDNTRIBUTETOTHEpEATHT 28a.HA30RGANORTISSUEbONATIONBEENCDN5IDERE07 28b.WA5CONSEN7GRANTE07
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<br />NO ^ PflDBASLV ^ UNKNOWN ^ YES ~ND Not Appllce6le 1128a Is NO ^ YES (~ Nb
<br />^ YE5
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<br />~. 27. NAME Tr, IT~~ANDq[)pRE55OFCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Ty eorPrlnl)Prlnl)
<br />' '~ Dr. Anne K. Morse, M.D., 729 N. Custer, Grand Island NE 68$03
<br /> 28a.REGISTRAfl'SBIGNATURE
<br />~ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
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